The goal of this research study is to investigate whether Rituximab is safe to use in patients suffering from NMO, or who are at high risk for developing NMO. It is thought that NMO is caused by the immune system reacting against the optic nerves and spinal cord. B cells are a part of the immune system that may contribute to the illness. Rituximab is an antibody that depletes B cells. Depletion of these B cells with Rituximab may induce remission of the disease. Because pathological and serological studies suggest that NMO appears to be, at least in part, a B-cell mediated disease Rituximab, is an attractive treatment candidate for this disease.

Rituximab is a highly purified, 1328-amino acid antibody with an approximate molecular mass of 145 kD. Rituximab is a sterile, clear, colorless, preservative-free liquid concentrate for intravenous (IV) administration. Rituximab is supplied at a concentration of 10 mg/mL in either 100 mg (10 mL) or 500 mg (50 mL) single-use vials. In this single arm study all subjects are treated with two cycles of rituximab. Each cycle consists of two 1000 mg infusions administered two weeks apart. The cycles of rituximab treatment are administered at baseline and at 9 months.

Other Name: Rituxan

Detailed Description:

Rituximab is a genetically engineered, chimeric, murine/human monoclonal antibody directed against the CD20 antigen found on the surface of normal and malignant pre-B and mature B cells. The antibody is an IgG1 immunoglobulin containing murine light- and heavy chain variable region sequences and human constant region sequences. Rituximab is composed of two heavy chains of 451 amino acids and two light chains of 213 amino acids (based on cDNA analysis) and has an approximate molecular mass of 145 kD. Rituximab has a binding affinity for the CD20 antigen of ~8.0 nM.

Rituximab was developed by Biogen Idec and Genentech, Inc. It was approved by the FDA in 1997 for the treatment of relapsed or refractory low grade or follicular, CD20+, B-cell non-Hodgkin's lymphoma (NHL).

Rituximab has also been studied in a variety of non-malignant autoimmune disorders where B cells and auto antibodies appear to play a role in pathophysiology. Rituximab has been reported to relieve signs and symptoms of rheumatoid arthritis , lupus , immune thrombocytopenia , autoimmune anemia , autoimmune neuropathy , and paraneoplastic opsoclonus/myoclonus .

A Phase II study (WA16291) has been completed in patients with rheumatoid arthritis (RA) . A total of 161 patients were randomized to 4 treatment arms: Methotrexate, Rituximab alone, Rituximab and Methotrexate, Rituximab and Cyclophosphamide. Two doses of Rituximab, 1 gm each, were administered IV two weeks apart. Infusion reactions were observed in 36% of patients during their first infusion of Rituximab compared to 30% for placebo . Four Rituximab-treated patients developed serious infections, for a rate of 4.6 per 100 patient years. For context, the rate of infections requiring hospital admission was 9.57 per 100 patient years in a community based epidemiologic study in RA.

We treated 8 patients with NMO with Rituximab and observed that Rituximab appears to be well tolerated with 0/8 of the patients suffering serious adverse reactions that could be directly related to Rituximab administration. Moreover, 7/8 patients experienced decrease in neurological disability following treatment, suggesting that B-cell depletion may enhance neurological recovery from attacks. 7/8 of the patients remained attack-free within a period of 18 months of follow-up on average (range 3 to 12 months) following treatment. We observed one attack following treatment in a single patient, whereas 14 attacks would have been predicted by the pre-treatment attack rate (p=0.012, paired t test comparing pre- and post-treatment attack rates). Nevertheless, the observed impact of treatment on recovery is more than what would be expected from spontaneous recovery and deserves further investigation. If B cells are essential for pathogenesis of recurrent attacks in NMO, B cell depletion may induce sustained remission. We also observed in one case, a dramatic recovery of electrophysiological conduction in the optic nerves (visual evoked potentials), which implies that in this case, rituxan did not impair repair mechanisms, for example, demyelination following the acute attack.

Eligibility

Ages Eligible for Study:

12 Years to 86 Years (Child, Adult, Senior)

Genders Eligible for Study:

Both

Accepts Healthy Volunteers:

No

Criteria

Inclusion criteria

Criteria for neuromyelitis optica:

acute transverse myelitis and optic neuritis occurring within 30 days of each other followed by a second attack of either optic neuritis and/or acute transverse myelitis at least 3 months following the heralding attack OR

acute transverse myelitis followed by optic neuritis at least 3 months later OR

optic neuritis followed by acute transverse myelitis at least 3 months later

Criteria for high risk for neuromyelitis optica:

recurrent idiopathic recurrent acute transverse myelitis with at least 3 months time between each attack OR

recurrent bilateral simultaneous optic neuritis with at least 3 months time between each attack.

Subjects should also have no clinical evidence of disease outside the optic nerve or spinal cord.

In addition patients should have one major supportive criteria OR two minor supportive criteria:

Severe optic neuritis with fixed visual acuity worse than 20/200 in at least one eye

Severe, fixed, attack-related weakness (MRC ≤2) in one or more limbs

Subjects must have exhibited evidence of treatment failure, defined as at least one attack of either acute transverse myelitis or optic neuritis within six months of screening despite treatment within steroids or other immunomodulatory drug for the preceding attack.

Able and willing to give written informed consent and comply with the requirements of the study protocol.

Adequate liver function, as indicated by normal bilirubin and alkaline phosphatase, and transaminases (AST and ALT) within 2X upper limit of normal.

Negative serum pregnancy test (for women of child bearing age).

Men and women of reproductive potential must agree to use an acceptable method of birth control during treatment and for twelve months (1 year) after completion of treatment.

Exclusion Criteria:

Treatment with broad-spectrum immunosuppressant medications such as cyclophosphamide, mitoxantrone, methotrexate, azathioprine, and cladribine, within 60 days of screening.

Treatment with any investigational agent within 4 weeks of screening

Receipt of a live vaccine within 4 weeks prior to randomization

Previous Treatment with Rituximab (MabThera® / Rituxan®)

Prior antibody therapy

History of exposure to clioquinol

History of severe allergic or anaphylactic reactions to humanized or murine monoclonal antibodies

History of HIV (positive HIV, HIV conducted during screening if applicable)

History of Hepatitis B and/or Hepatitis C (Hep B/C at screening)

History of recurrent significant infection or history of recurrent bacterial infections

Known active bacterial, viral fungal mycobacterial, or other infection or any major episode of infection requiring hospitalization

Ongoing daily steroid use

History of drug, alcohol, or chemical abuse within 6 months prior to screening

Pregnancy (a negative serum pregnancy test should be performed for all women of childbearing potential within 7 days of treatment) or lactation

Concomitant malignancies or previous malignancies within the last five years, with the exception of adequately treated basal or squamous cell carcinoma of the skin or carcinoma in situ of the cervix.

History of psychiatric disorder

Contacts and Locations

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study.
To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below.
For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00501748

Locations

United States, California

UCSF MS Center , 350 Parnassus Ave , suite #908

San Francisco, California, United States, 94117

United States, New York

The Neurological Institute of New York MS Center

Columbia University Medical Center 710 West 168th Street,, New York, United States, 10032